NIA Magellan 1 Hip, Knee & Spine Surgery Frequently Asked Questions (FAQs) for Florida Blue Medicare Advantage BlueMedicare SM HMO and PPO Plans

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1 NIA Magellan 1 Hip, Knee & Spine Surgery Frequently Asked Questions (FAQs) for Florida Blue Medicare Advantage BlueMedicare SM HMO and PPO Plans Question GENERAL Why is Florida Blue implementing a Musculoskeletal Management program focused on hip, knee and spine surgeries? Why did Florida Blue select NIA Magellan to manage its musculoskeletal surgeries? Which Florida Blue members will be covered under this relationship and what networks will be used? PROGRAM START DATE What is the implementation date for the Musculoskeletal Management program? PRIOR AUTHORIZATION Answer The Musculoskeletal Management program is designed to improve quality and manage the utilization of non-emergent* surgeries, occurring in outpatient and inpatient settings. Musculoskeletal surgeries are a leading cost of health care spending trends Variations in patient care exist across all areas of surgery (care prior to surgery, type of surgery, surgical techniques and tools, and post-op care) Diagnostic imaging advancements have increased diagnoses and surgical intervention aligning with these diagnoses rather than patient symptoms Medical device companies marketing directly to consumers Surgeries are occurring too soon leading to the need for additional or revision surgeries. * NIA Magellan 1 does not manage prior authorization for emergency Musculoskeletal Surgery cases that are admitted through the Emergency Room or for select musculoskeletal procedures outside of those procedures falling within this program. NIA Magellan was selected to partner with us because of its clinically-driven program designed to effectively manage the quality, patient safety and ensure appropriate utilization of resources for Florida Blue membership. NIA Magellan will manage non-emergent outpatient and inpatient for hip, knee and spine surgeries for Medicare Advantage BlueMedicare HMO and PPO members effective January 1, 2016, through Florida Blue s contractual relationships. The program start date is January 1, Florida Blue and NIA Magellan will be collaborating on provider related activities prior to the start date including provider announcements, and provider education. 1 NIA Magellan refers to National Imaging Associates, Inc. 1 Musculoskeletal Management Frequently Asked Questions for Florida Blue Medicare

2 What surgeries require prior authorization before the procedure is performed? The following hip, knee and spine surgery procedures require prior authorization* through NIA Magellan: Hip: Revision/Conversion Hip Arthroplasty Total Hip Arthroplasty/Resurfacing Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincher & labral repair) Hip Surgery Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy Knee: Knee Revision Knee Arthroplasty Total Knee Arthroplasty (TKA) Partial-Unicompartmental Knee Arthroplasty (UKA) Knee Manipulation under Anesthesia (MUA) Knee Ligament Reconstruction/Repair Knee Meniscectomy/Meniscal Repair/Meniscal Transplant Knee Surgery Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration) Spine: Lumbar Microdiscectomy Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy) Lumbar Spine Fusion (Arthrodesis) With or Without Decompression Single & Multiple Levels Cervical Anterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression (without fusion) Cervical Artificial Disc Replacement Cervical Anterior Decompression (without fusion) *For a full listing the CPT codes associated with each procedure please see the Utilization Matrix posted on RadMD.com. When is prior authorization required? Prior authorization is required through NIA Magellan for inpatient and outpatient non-emergent hip, knee and spine surgeries. The ordering physician must obtain prior authorization with NIA Magellan prior to performing these procedures and prior to obtaining the prior authorization with the Florida Blue for the facility or hospital admission. Bilateral surgeries: The surgeon must request surgery authorization for each joint, even if bilateral joint surgery is to be performed on the same date. 2 Musculoskeletal Management Frequently Asked Questions for Florida Blue Medicare

3 Is a prior authorization required for patients who already have a musculoskeletal surgery scheduled? Who can order a musculoskeletal surgery? Are inpatient surgeries included in this prior authorization program? Who will be reviewing the surgery requests and medical information provided? Does the NIA Magellan prior authorization process change the requirements for facilityrelated prior authorization? How does the ordering physician obtain a prior authorization from NIA Magellan? What information will NIA Magellan require in order to receive prior authorization? Note: Any Florida Blue prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery has met NIA Magellan medical necessity criteria. Yes. Any non-emergent hip, knee and spine surgery performed on or after, January 1, 2016, requires a prior authorization through NIA Magellan. Musculoskeletal surgeries requiring medical necessity review are expected to be ordered by one of the following specialties: Orthopedic Surgeons Neurosurgeons Yes. All non-emergent outpatient and inpatient musculoskeletal surgeries outlined above are required to have a prior authorization through NIA Magellan. As a part of the NIA Magellan clinical review process, actively practicing, orthopedic surgeon specialists (hip and knee) or neurosurgeons (spine) will conduct the medical necessity reviews and determinations of musculoskeletal surgery cases. No. NIA Magellan s medical necessity review and determination is for the authorization of the surgeon s professional services and type of surgery being performed. NIA Magellan will provide Florida Blue with the surgery type requested and authorization determination. Florida Blue facilities must continue to follow Florida Blue s prior authorization processes for hospital admissions and elective surgery. Note: Any Florida Blue prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery has met NIA Magellan s medical necessity criteria. Ordering physicians will be able to request prior authorization via the NIA Magellan website at or by calling the NIA Magellan toll-free number To expedite the process, please have the following information ready before logging on to the website or calling the NIA Magellan Call Center (*denotes required information):for prior authorization of non-emergent inpatient and outpatient musculoskeletal surgeries: Name and office phone number of ordering physician* Member name and ID number* Requested surgery type* Name of facility where the surgery will be performed* Anticipated date of surgery* Details justifying the surgical procedure*: o Clinical Diagnosis* o Date of onset of back pain or symptoms /Length of time patient has had episode of pain* o Physician exam findings (including findings applicable to the requested services) 3 Musculoskeletal Management Frequently Asked Questions for Florida Blue Medicare

4 o o Diagnostic imaging results Non-operative treatment modalities completed, date, duration of pain relief, and results (e.g., physical therapy, epidural injections, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication) Does the ordering physician need a separate request for all musculoskeletal surgeries being performed during the same surgery on the same date of service? Please be prepared to provide the following information, if requested: Clinical notes outlining type and onset of symptoms Length of time with pain/symptoms Non-operative care modalities to treat pain and amount of pain relief Physical exam findings Diagnostic Imaging results Specialist reports/evaluation No. NIA Magellan will provide a list of Surgery categories to choose from and the Florida Blue Surgeon must select the most complex and invasive Surgery being performed as the primary Surgery. Example: Lumbar Fusion If the Florida Blue surgeon is planning a single level lumbar spine fusion with decompression, the surgeon will select the single level fusion procedure. The surgeon does not need to request a separate authorization for the decompression procedure being performed as part of the lumbar fusion surgery. This is included in the lumbar fusion request. Example: Laminectomy If the Florida Blue surgeon is planning a laminectomy with a microdiscectomy, the surgeon will select the lumbar decompression procedure. The surgeon does not need to request a separate authorization for the microdiscectomy procedure. If the Florida Blue surgeon is only performing a microdiscectomy, the surgeon should select the microdiscectomy only procedure. NOTE: Bilateral surgeries: The surgeon must request surgery authorization for each joint, even if bilateral joint surgery is to be performed on the same date. Will the ordering Physician need to enter each CPT procedure code being performed within the MSK surgery? Are instrumentation (medical device), bone grafts, and bone marrow aspiration included as part of the authorizations? What kind of response time can ordering physician expect for prior authorization? No. NIA Magellan will provide a list of surgery categories to choose from and the ordering physician must select the primary surgery (most complex) being performed. There will be a summary of which CPT codes fall under each procedure category. Yes. The instrumentation (medical device), bone grafts, and bone marrow aspiration procedures commonly performed in conjunction with musculoskeletal surgeries are included in the authorization; however, the amount of instrumentation must align with the procedure authorized. Having the following information available prior to calling NIA Magellan at or online through will create the most efficient response for a medical necessity decision. Clinical diagnosis Date of onset of back pain or symptoms /Length of time patient has had episode of pain 4 Musculoskeletal Management Frequently Asked Questions for Florida Blue Medicare

5 Physician exam findings (including findings applicable to the requested services) Pain/patient symptoms Diagnostic imaging results Non-operative treatment modalities completed, date, duration of pain relief, and results (e.g., physical therapy, epidural injections, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication) Generally, within 2 business days after receipt of request with full clinical documentation, a determination will be made. In certain cases, the review process can take longer if additional clinical information is required to make a determination. What will the NIA Magellan authorization number look like? If requesting authorization through RadMD and the request pends, what happens next? Can RadMD be used to request retrospective or expedited authorization request? How long is the prior authorization number valid? Is prior authorization necessary for lumbar, cervical, spine, hip or knee surgery if Florida Blue is NOT the member s primary insurance? If an ordering physician obtains a prior authorization number does that guarantee payment? Does NIA Magellan allow In certain cases, the review process can take longer if additional clinical information is required to make a determination. The NIA Magellan authorization number will consist of 8 or 9 alpha-numeric characters. In some cases, the ordering surgeon may receive an NIA Magellan tracking number instead (not the same as an authorization number) if the surgeon s authorization request is not approved at the time of initial contact. Ordering physicians will be able to use either number to track the status of their request online or through an Interactive Voice Response (IVR) telephone system. You will receive a tracking number and NIA Magellan will contact you to complete the process. No. Those requests will need to be called into NIA Magellan s Call Center for processing at For outpatient surgeries the authorization is valid for 90 days from the date of service. For inpatient surgeries the authorization is valid for 5 days from the date of service. No An authorization number is not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits. Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. NIA Magellan s medical necessity review and determination is for the authorization of the surgeon s professional services and type of surgery being performed. Any Florida Blue prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery has met NIA Magellan s medical necessity criteria. It is important that key physicians and office staff be educated on the prior 5 Musculoskeletal Management Frequently Asked Questions for Florida Blue Medicare

6 retro-authorizations? authorization requirements. Claims for hip, knee or spine surgery, as outlined above, that have not been properly authorized will not be reimbursed. Can an ordering physician verify an authorization number online? Will the NIA Magellan authorization number be displayed on the Florida Blue Web site? What if I disagree with NIA Magellan s determination? SCHEDULING PROCEDURES Do ordering physicians have to obtain an authorization before they call to schedule an appointment? Will NIA Magellan make a final determination based upon the anticipated date of service? Physicians performing hip, knee or spine surgery should not schedule or perform surgery without prior authorization. Yes. Ordering physicians can check the status of member authorization quickly and easily by going to the Web site at No. WHICH MEDICAL SURGEONS ARE AFFECTED? Which physicians are impacted by the Musculoskeletal Management program? CLAIMS RELATED Where do rendering providers/surgeons send their claims for outpatient, non-emergent Musculoskeletal Management Program services? How can claims status be checked? Who should a surgeon contact if they want to appeal a prior authorization or claims payment denial? MISCELLANEOUS In the event of prior authorization or claims denial, providers may appeal the decision through the Florida Blue appeal procedure. Providers should follow the instructions on the authorization denial letter or Explanation of Benefit (EOB) notification. NIA Magellan asks where the surgery is being performed and the anticipated date of service. Ordering physicians should obtain prior authorization before scheduling the patient and the facility or hospital admission. NIA Magellan does not guarantee final determination of the request by the anticipated date of service. Please be advised NIA needs 2-3 business days after the receipt of clinical information to review a request. Please do not perform surgery until you have an approved authorization. Orthopedic Surgeons and Neurosurgeons and are the key physicians impacted by this program. All procedures performed in any setting are included in this program: Hospital (inpatient and outpatient settings) Ambulatory surgical centers Florida Blue s rendering providers/ surgeons should continue to send claims directly to Florida Blue. Rendering providers/surgeons are encouraged to use EDI claims submission. Rendering providers/surgeons should continue to check claims status at the Florida Blue website: Rendering providers/surgeons are asked to please follow the appeal instructions given on their non-authorization letter or Explanation of Benefits (EOB) notification. 6 Musculoskeletal Management Frequently Asked Questions for Florida Blue Medicare

7 How is medical necessity defined? How will referring/ordering surgeons know who NIA Magellan is? Will ordering physician trainings be offered closer to the January 1, 2016 implementation date? Where can an ordering physician find NIA Magellan s Guidelines for Clinical Use of MSK Management Procedures? What will the member ID card look like? Will the ID card have both NIA Magellan and Florida Blue information on it? Or will there be two cards? CONTACT INFORMATION What if a surgeon needs more information from NIA Magellan? Medical necessity means services that: Meets generally accepted standards of medical practice; be appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient evidence and professionally recognized standards; Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome; Be appropriate to the intensity of service and level of setting; Provide unique, essential, and appropriate information when used for diagnostic purposes; Be the lowest cost alternative that effectively addresses and treats the medical problem; and rendered for the treatment or diagnosis of an injury or illness; and not furnished primarily for the convenience of the member, the attending physician, or other surgeon. Florida Blue will mail notification letters and educational materials to plan surgeons. Florida Blue and NIA Magellan are also conducting educational trainings for plan surgeons. Yes. NIA Magellan will conduct webinar training sessions prior to the implementation date. NIA Magellan s Clinical Guidelines can be found on the Web site at or They are presented in a PDF file format that can easily be printed for future reference. NIA Magellan s clinical guidelines have been developed from practice experiences, literature reviews, specialty criteria sets and empirical data. The Florida Blue Member ID card will not change and will not contain any NIA Magellan identifying information on it. Ordering physicians can contact NIA Magellan Provider Relations, Manager: Michele DeCaprio at (800) ext Musculoskeletal Management Frequently Asked Questions for Florida Blue Medicare